Mast Cells: A New Target in the Treatment of Complex Regional Pain Syndrome?

Pain Practice

1. Maaike Dirckx MD^1,*, 
2. George Groeneweg PT, PhD¹, 
3. Paul L. A. van Daele MD, PhD²,
4. Dirk L. Stronks PhD¹, 
5. Frank J. P. M. Huygen MD, PhD¹

Article first published online: 14 MAR 2013

DOI: 10.1111/papr.12049

Abstract

There is convincing evidence that inflammation plays a pivotal role in the pathophysiology of complex regional pain syndrome (CRPS). Besides inflammation, central sensitization is also an important phenomenon. Mast cells are known to be involved in the inflammatory process of CRPS and also play a role (at least partially) in the process of central sensitization. In the development of a more mechanism-based treatment, influencing the activity of mast cells might be important in the treatment of CRPS. We describe the rationale for using medication that counteracts the effects of mast cells in the treatment of CRPS.

Treatment of Chronic Migraine

CURRENT PAIN AND HEADACHE REPORTS

DOI: 10.1007/s11916-010-0159-x

Hans-Christoph Diener, Dagny Holle and David Dodick

Abstract

Chronic migraine is defined in different ways. The most commonly used definition is headache on more than 15 days per month in patients with migraine. Chronic migraine is difficult to treat and requires a multidisciplinary approach. Only two pharmacological treatments have been shown to be effective in placebo-controlled randomized trials: topiramate and local injection of botulinum toxin. Both therapies are effective in patients with chronic migraine with and without medication overuse. Many other substances have been investigated in chronic daily headache. All trials were underpowered and, therefore, recommendations concerning possible efficacy are not possible.

Advances in Neuropathic Pain Diagnosis, Mechanisms, and Treatment Recommendations

Arch Neurol. 2003;60:1524-1534.
Robert H. Dworkin, PhD; Miroslav Backonja, MD; Michael C. Rowbotham, MD; Robert R. Allen, MD; Charles R. Argoff, MD; Gary J. Bennett, PhD; M. Catherine Bushnell, PhD; John T. Farrar, MD; Bradley S. Galer, MD; Jennifer A. Haythornthwaite, PhD; David J. Hewitt, MD; John D. Loeser, MD; Mitchell B. Max, MD; Mario Saltarelli, MD, PhD; Kenneth E. Schmader, MD; Christoph Stein, MD; David Thompson, PhD; Dennis C. Turk, PhD; Mark S. Wallace, MD; Linda R. Watkins, PhD; Sharon M. Weinstein, MD

ABSTRACT
Chronic neuropathic pain, caused by lesions in the peripheral or central nervous system, comes in many forms. We describe current approaches to the diagnosis and assessment of neuropathic pain and discuss the results of recent research on its pathophysiologic mechanisms. Randomized controlled clinical trials of gabapentin, the 5% lidocaine patch, opioid analgesics, tramadol hydrochloride, and tricyclic antidepressants provide an evidence-based approach to the treatment of neuropathic pain, and specific recommendations are presented for use of these medications. Continued progress in basic and clinical research on the pathophysiologic mechanisms of neuropathic pain may make it possible to predict effective treatments for individual patients by application of a pain mechanism–based approach. An evidence-based treatment approach is becoming feasible as the number of published randomized controlled trials continues to grow steadily. In this article, we discuss the diagnosis and assessment of neuropathic pain and survey recent research on pathophysiologic mechanisms. Evidence-based treatment recommendations for the pharmacologic management of chronic neuropathic pain are presented that take into account clinical effectiveness, adverse effects, influence on quality of life, and cost.

Free Full Text: http://archneur.ama-assn.org/cgi/content/full/60/11/1524

Riboflavin prophylaxis in pediatric and adolescent migraine

The Journal of Headache and Pain
Volume 10, Number 5 / October, 2009
Maria Condò1, Annio Posar1, Annalisa Arbizzani1 and Antonia Parmeggiani1

(1) Child Neurology and Psychiatry Unit, Department of Neurological Sciences, University of Bologna, Via Ugo Foscolo 7, 40123 Bologna, Italy

Received: 24 April 2009 Accepted: 10 July 2009 Published online: 1 August 2009

Abstract Migraine is a common disorder in childhood and adolescence. Studies on adults show the effectiveness and tolerability of riboflavin in migraine prevention, while data on children are scarce. This retrospective study reports on our experience of using riboflavin for migraine prophylaxis in 41 pediatric and adolescent patients, who received 200 or 400 mg/day single oral dose of riboflavin for 3, 4 or 6 months. Attack frequency and intensity decreased (P < 0.01) during treatment, and these results were confirmed during the follow-up. A large number of patients (77.1%) reported that abortive drugs were effective for controlling ictal events. During the follow-up, 68.4% of cases had a 50% or greater reduction in frequency of attacks and 21.0% in intensity. Two patients had vomiting and increased appetite, respectively, most likely for causes unrelated to the use of riboflavin. In conclusion, riboflavin seems to be a well-tolerated, effective, and low-cost prophylactic treatment in children and adolescents suffering from migraine.

Antonia Parmeggiani
Email: antonia.parmeggiani@unibo.it

Utilization, diagnosis, treatment and cost of migraine treatment in the emergency department.

Headache. 2009 Sep;49(8):1163-73.
Links
Utilization, diagnosis, treatment and cost of migraine treatment in the emergency department.
Friedman D, Feldon S, Holloway R, Fisher S.
University of Rochester, Neurology, Rochester, NY, USA.
OBJECTIVE: To determine the percentages of patients receiving migraine-specific therapy and to estimate the rate of unnecessary neuroimaging studies in the emergency department (ED). METHODS: A retrospective study was conducted analyzing medical records and hospital charge data of ED visits for migraine during 2005 in 2 university-affiliated hospitals. Following a preliminary review of 23 randomly selected ED charts selected to determine the reliability of the coding process, 172 other charts were selected to include 1 visit per patient with a primary discharge diagnosis code of 346.0, 346.1, or 346.9. The diagnosis of migraine was confirmed using predefined criteria. Demographic information, treatment strategies, laboratory and neuroimaging tests, response to therapy, discharge planning, and charge data were evaluated. RESULTS: Of 156 patients with completed visits, neuroimaging studies were performed in 36 patients (23%), and only 4 patients had no documented justification for obtaining imaging studies. Seventy-eight patients (50%) had a potential contraindication to receiving migraine-specific therapy. Nine patients (11.5% of eligible patients) received migraine-specific therapy. Most patients were treated with a combination of parenteral antiemetics, narcotics, or ketorolac. CONCLUSION: This analysis supports previous studies indicating the underutilization of migraine-specific treatment in the ED, and suggests that the ED is generally used as a "last resort" when the patient's home medication fails. Because of various contraindications, migraine-specific medications may not be a treatment option in up to 50% of patients seen in the ED. Although almost all of the neuroimaging studies were justified, the radiology charges were a major contributing factor to the overall financial burden of emergency migraine care.
PMID: 19719544 [PubMed - in process]